HomeMy Public PortalAbout5613 HELEO AVE_Sewer__ °
CE808-e-aa APPLICATION FOR PERMIT 1
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 561 Heleo
M
JOHN A. LABIE, County Engine.. ADDRESS
CASSATT D. GRIFFIN, Supt of Building LOCALITY Temple City
NEAREST roa way
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL e
DESCRIPTION LOT NO. 14 OWNER
BLOCK TRACT 25202 AO
DIE S 21121 Mesa Rica Road�
SIZEOF LOT NOWOON LOTS CITY VZ a TEL.NO.ED 2-/ 7/[ 25
USE OF Res.
BUILDINGS DISTRICT N0. GROUP BK PG MAP PliDGG4iSED BY
CONTRACTOR D
ADDRESS 5136 No. Bleeker CONNECTION DATA
cITYBaldwin Park TEL. HOED 8-3024 STATION 3 DEPTH
STATE MANHOLE REFERENCE
REGISTRATION N0. COUNTY "7
NO. DESCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO T
PUBLIC SEWER @ SS.00TYPE OF CONNECTION LENGTH FROM -J �7SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TOP.L OL /PITS ANO/OR DRAINFIELO @ §5.00OVERFLOW SEEPAGE PIT, DRATNFIELD
EXTN.,CESSPOOL.DRYWELL,MA NHOLE@ §2.00HOUSE SEWER CONNECTING TO P.C. NO.PRIVATE DISPOSAL SYSTEM @ §1.00CO.IMP.NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ §1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION FTOTIMFEE 0-0 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVAIS DATE INPE
_SCTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS-------DAY OF 11_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL I]
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS At ELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM T AL OWNER OF TH AB___
DESCRIBED RESID P 0 �T ACKSEEP. PIT S)ILL POQ TANKS CESSPOOLS ❑
SIGNATURE L<
OF PERMITTEE
1®. ALIDATION ROBERTA.WOOD
Ca. Y.o. CASH SUPERVISING MECHANICAL ENGINEER
�d{ g 0 9 3 6 i'lily 18 1 0 A 5.00 �°